Building on the work of Rachael Aylmer, Beki Brain, Jo Buchmuller, John Burnham, Shila Desai and Jill Lubienski, this article sets out a rationale for using the principles of Non-violent resistance to support phase 1 of Family-Based Treatment for eating disorders. It offers some practical exercises practitioners may wish to use or adapt in their own practice.
Background:
Since its conception, Family-Based Treatment (FBT) based on guidance from the ‘Maudsley manual’ (Lock & Le Grange, 2005) has been the evidence-based treatment of choice for young people experiencing Anorexia. Not without good reason: For the majority of non-complex cases, FBT remains a highly effective approach. However, in post-COVID times we have seen growing presentations of atypical eating disorders, including increased rates of ARFID presentations as well as co-morbidity with other mental health difficulties (Trafford et al, 2023). The lines between Eating Disorders and other presentations are increasingly blurry. Consequently, in a growing number of cases, parents report or demonstrate difficulty in implementing the approaches recommended in FBT.
Frequently parents come into ED services feeling overwhelmed by trying to care for their child, who is struggling with a life-threatening illness. Often, simultaneously trying to protect close friends and other family members by concealing the difficulties. This adds a layer of complexity, increases feelings of isolation and compounds stress levels that are already high.
Fear of making things worse – of exacerbating the ED or losing their relationship with their child (or both) can lead to a paralysis of assertive action, which may lead to parents adopting a “something is better than nothing mindset”, or even a defensiveness about recommended approaches.
Expressions of anger/(di)stress from both child and parent can quickly escalate as we encourage parents to challenge their child to face their biggest fear, food – multiple times per day. These escalatory relationship patterns can halt the treatment process and often maintain the problem.
“The child’s external expression of anger can be seen as an attempt to gain autonomy…distracting from the treatment process” (Lubienski & Buchmuller, 2021).
In the resultant powerlessness and desperation to make things better, an understandable parental response is to increase attempts to control their child. The child, as they try to hold on to what little control they feel they have remaining, can often dig their heels in. A pattern of symmetrical escalation ensues. Alternatively, parents feel they “have tried everything” lose faith in the approach and back away from supporting their child for fear of harming the relationship. Treatment progress halts, whilst relationships suffer. Helping parents to regulate their own escalatory responses creates a home environment that is far more likely to support re-feeding. NVR can offer hope when parents feel like they have tried everything.
“Conflict-avoidant parenting styles can unwittingly maintain the eating disorder” (Lock & LeGrange, 2005, p. 192)
In cases such as these, embracing the principles of NVR might offer an alternative approach that could increase: parental self-control, self-confidence, sense of efficacy and therefore action.
In the ‘re-feeding’ phase of treatment, we ask parents to take a position that may cause both their child and themselves distress, multiple times per day: NVR principles can be utilised to coach parents to tolerate their child’s distress and to know that their own actions are coming from a place of vigilant care and love. Parents are the first-line intervention in FBT. An NVR approach recognises the suffering of parents and works with parents to support them to support their child. (Aylmer & Lubienski, 2021).
As well as being utilised in eating disorders work to treat anorexia, an adaptation of NVR has been demonstrated in clinical trials to be an effective treatment for ARFID (Shimshoni & Lebowitz, 2020). What follows is a small selection of practical exercises that practitioners may wish to use as part of ED or generic NVR work.
De-escalation:
As NVR practitioners we are familiar with helping parents to identify their ‘buttons’ – actions, words, situations of behaviours that ‘hook’ parents into giving responses they may not choose in less stressful situations. We can use the following resources to help parents reflect on these ‘buttons’ and to author alternative responses.
Sequencing:
When hearing from parents about a difficult mealtime, we can often focus on what was going on for the child, their struggles, their emotions and their responses. However, as in NVR we invite parents to be the main agent of change, using sequencing to help parents better understand what was going on for them, during their child’s struggle, can be useful.
Parents can be supported to:
- Map out a mealtime escalation as above.
- Identify main events, then add parents’ emotions and meanings attached to actions. Identify buttons and trigger points.
- What emotions/feelings/expectations were present even before the meal started? (think emotional postures; Fredman, 2007)
Chain reaction:
Once we have identified ‘buttons’ or ‘hot spots’ we can use a ‘chain reaction’ model to help parents unpick what’s going on for them behind their responses. Bringing an awareness to why these ‘buttons’ are present for parents creates an opportunity to let go of their automatic responses.
Cultural and societal norms, when coupled with messages from our families of origin inform the ‘expectations’ we set for ourselves and others. Liberating ourselves from these ‘expectations’ and setting our own, new expectations, can be a helpful way to de-escalate.
Escalation dance
This diagram takes the chain reaction model and shows the cyclical nature of escalation. Whether we react in an escalatory or regulated way, over time, or responses become the culture. Long-term change in NVR comes via the accumulation of small episodes. Consistent with Mason’s equation for change (2020), committing to the principles of non-violence and applying them over time, creates a lasting, second-order change in relationships. It’s a way of being that we can pass on to our children, through our actions.
Parental disobedience
In NVR terms, ‘orders’ are things we do or comply with for fear of the response or reprisal from our child. For example: Buying diet or low-calorie foods, giving smaller portions, not challenging anorectic cognitions, allowing them to skip meals. ‘Taboos’ are things we don’t do, have stopped doing, or are scared to do for the same reason. For example: Not going to restaurants, not getting take-aways, not talking about food in their presence. When your child is suffering it is completely natural to try and take-away their pain in any way you can. What parent wouldn’t? However, in doing so we can inadvertently start to side with the eating disorder. We invite parents to take an inventory of the ways that they might be complying with the wishes of the eating disorder, rather than being the parents they would like to be.
“Each act of parental disobedience opens up new possibilities for the family.” Omer 2004
It may feel like it to your child but refusing orders / breaking taboos is not a punishment. It’s a refusal to comply with the wishes anorexia has for your child.
- These changes are calmly/ implemented
- There is no requirement to discuss this change in your behaviour, a short supportive statement will suffice
- How do you anchor yourself? How will you employ your imaginary shield?
- How can your supporters help?
Announcement:
As NVR practitioners, we are all familiar with the power of the announcement. We can coach parents to write announcements to their child to give a message that they will do everything they can to support their child through their illness. They will not be dismissed. Announcements mark a commitment to the NVR approach and demonstrate a change in parental response. There is opportunity within an announcement to own and apologise for any parental behaviours, adopted out of desperation or frustration that are not consistent with a non-violent approach. It’s a therapeutic love letter to the child that demonstrates, even though it’s difficult for you, you are committed to your child’s wellbeing and your relationship with your child, and you won’t let their illness get in the way of that. One other way I have been using announcements is to give messages of support to parents. To help keep them on track, and to bolster their resilience as they work hard as the first-line support for their child. For example:
Dear Megan,
I wanted to remind you how well you are doing. You’re a great parent who loves your daughter dearly. You have committed so much time and effort to help them get well – and you continue to do so tirelessly, often in the face of great resistance from her. There are times you would have done anything to help to stop your child from being in pain – which parent wouldn’t – but you have come to realise that letting them miss a meal or choose the low-calorie option in the supermarket is ultimately hurting them more than helping. You’ve started to reach out to your friends for help and have been pleasantly surprised with how positively they have responded. You don’t have to do this on your own you know. Look after yourself. Parenting a teenager is hard work at the best of times, let alone when they are struggling with anorexia. Remember to make some time for you, to help you be strong for your daughter. You are doing the most important job in the world – keep going!
Luke
Over the last ten years of working with NVR, I have seen ideas from the approach become useful to parents struggling to support their child with issues such as: violence, aggression, drug use, school refusal, risky sexual behaviours, property damage and social withdrawal to name but a few. I have seen parents move from feeling like helpless bystanders to active agents in supporting their child. In more recent times I have seen how eating disorders can hijack family relationships, alienate children from the supportive adults around them and disrupt the lives of those suffering from the illness as well as their loved ones. My hope is that the principles of NVR can be an effective way of resisting the influences of anorexia and help to reunite families against it.
Written by Luke Cousins,
Systemic Psychotherapist, Person-Centred Counsellor
NVR Association (NVRA) Accredited Practitioner & Supervisor
Accreditation Module Participant, 2023
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References:
- Aylmer, R. & Lubienski, J. (2021). Integrating NVR in the Maudsley model for eating disorders. https://www.youtube.com/watch?v=DORiNtCzklc
- Buchmuller, J. & Lubienski, J. (2021). The Chicken or the egg: Anger, aggression, and anorexia. Context 175, 23-25
- Burnham, J. & Brain, B. (2021). (2021). Connections which pattern: NVR feeds an eating disorder programme. Context 175, 26-28
- Desai, S. (2023). It’s all in a mango: NVR and Eating Disorders. https://www.partnershipprojectsuk.com/its-all-in-a-mango-nvr-and-eating-disorders/
- Fredman, G. (2007). Preparing ourselves for the therapeutic relationship. Revisiting ‘Hypothesizing Revisited’. Human Systems: The Journal of Systemic Consultation and Management. 18. 44-59.
- Le Grange, D. (2005) The Maudsley family-based treatment for adolescent anorexia nervosa. World Psychiatry. 4(3):142-6
- Mason, B. (2020). Family of origin scripts in coping with adversity: a question. Journal of Family Therapy, 42(1): 4-14.
- Omer, H. (2004). Non-Violent Resistance: A New Approach to Violent and Self-destructive Children. Cambridge Uni Press.
- Shimshoni, Y., Silverman, W. K., Lebowitz, E. R. (2020) SPACE-ARFID: A pilot trial of a novel parent-based treatment for avoidant/restrictive food intake disorder. Int J Eat Disord 53: 1623– 1635